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FOUNDATION OVERVIEW

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General Overview

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Dyslipidemia is defined as elevated total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), triglycerides (TG), or low high density lipoprotein cholesterol (HDL-C). LDL-C incites the atherosclerotic inflammatory response promoting unstable lesions concentrated with lipid-laden macrophages. The degree of LDL-elevation is proportionally linked with risk of developing atherosclerotic cardiovascular disease (ASCVD)(1 mg/dL:1% change). Elevated TG has indirect atherosclerotic effects from procoagulant properties and an adverse impact on endothelial function. In contrast, HDL-C is an inverse predictor for ASCVD risk (1 mg/dL:2% change) due to reverse cholesterol transport (delivering cholesterol from the cell wall to the liver for disposal). Additionally, HDL-C inhibits LDL-C oxidation and platelet aggregation and activation.

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Dyslipidemia is a risk factor for ASCVD, defined as coronary heart disease, cerebrovascular disease, or peripheral artery disease. Dyslipidemia is asymptomatic until vascular disease develops. Patients may present with pain or cramping with walking, cold extremities, shortness of breath, chest pain, sweating, difficulty with speech or movement, and sudden death. Severe hypertriglyceridemia (TG >1000 mg/dL) can lead to abdominal pain, nausea, vomiting, and other symptoms of pancreatitis.

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Diagnosis

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For adults 20 years of age or older a lipid profile is recommended once every 5 years after a 12-hour overnight fast. The National Cholesterol Education Program (NCEP) ATP III classifies optimal and abnormal findings (Table 2-1). If testing is non-fasting, only HDL-C and TC will be accurate, and follow-up fasting lipid panel (FLP) is required for TC greater than or equal to 200 or HDL-C less than 40 mg/dL. The LDL-C can be measured directly or calculated using the Friedewald equation (LDL-C = TC − HDL-C − TG/5). The calculation is less accurate when TG are greater than 200 and inaccurate greater than 400 mg/dL.

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Table Graphic Jump Location
TABLE 2-1Classification of Total-, LDL-, HDL-C, and TG
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Secondary causes of dyslipidemia should be considered, such as obesity, obstructive liver disease, Cushing syndrome, tobacco use, alcohol overuse, hypothyroidism, anorexia nervosa, nephrotic syndrome, and undiagnosed or uncontrolled diabetes. TG levels can be lowered by improving glucose control. Many medications also increase cholesterol (eg, β-blockers, estrogens, androgens, thiazide diuretics, glucocorticoids, isotretinoin, protease inhibitors, mirtazapine, and cyclosporine). Conversely, acutely ...

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